Maxillary Third Molar Tooth Accidentally Displaced in Buccal Space: Report of Two Cases

The extraction of retained and completely impacted third molars is one of the most common surgical procedures performed by dental practitioners with low rates of complications. The accidental displacement during the surgeries of the maxillary third molar into adjacent anatomical spaces is one of the most critical problems that can arise. The most common sites of migration during surgical interventions are the infratemporal fossa, the pterygomandibular space, the maxillary sinus, the buccal space, and the lateral pharyngeal space. In this paper, two cases in which a maxillary third molar accidentally was displaced into the buccal space are presented, the retrieval of the tooth via intra-oral approach is explained, and the anatomical spaces implications are discussed.


Introduction
Post-operative complications can be observed during surgical extraction of third molars, such as uncountable bleeding, tooth root fracture, fracture of the tuberosity or the buccal bone, perforation of the sinus membrane, and prolapse of the buccal fat pad [1].
In the oral and maxillofacial region, many tissue spaces are inter-connected; consequently, a displaced tooth into one of these spaces can migrate to the others [10].
In this report, two cases of maxillary third molar that were moved accidentally toward the buccal space are described, and the extraction of the tooth via intraoral approach is explained. Moreover, this report reviews the anatomical spaces implications.

Case Presentation 1
A 25 -year-old male was referred to our oral surgery cl-inic after unintentional movement of the third molar in the left side of the maxilla during surgical procedure under local analgesia.
The pre-operative panoramic X-ray shows the initial position of the third molar ( Figure 1a). Intra oral palpation revealed a hard mass exists in the buccal space anterior to the coronoid process and the buccinator muscle was painful. A new panoramic X-ray radiograph showed that the third molar was displayed parallel to the second maxillary molar (Figure 1b

Case Presentation 2
A 16-year-old female was oriented to our surgical clinic by her dental practitioner. A surgical procedure was planned for an early removal of her left maxillary impacted molar for orthodontic reasons, but accidentally the tooth had been lost during the surgical procedure.
Pre-operative axial and sagittal CT cuts showed a third molar in a very high position in relation with an inflamed maxillary sinus membrane and a dentigerous cyst image that englobed the tooth (Figures 3a and b).  The new CT scan images showed that the molar was in the buccal space; it was jammed between the ramus and masseter and buccinator muscles, higher than the level the second molar for at least 2cm (Figures 4a and b).
The intra-oral palpation revealed the deep position of the tooth in the buccal vestibule. Local analgesia was given to the patient followed by a submucosal incision the tooth was approached via blunt dissection using Metzenbaum scissors then with a tissue forceps the crown was reached and rotated and pulled out true the incision line. As in the first case, the difficulty faced du-ring the surgical procedure was the dissection of the fibrous tissue and the tooth. After separating the third molar from the adipose tissue, it came out with the dentigerous cyst.
Then, the mucosal tissues were secured with separate sutures like in the first case (Figures 5a and b).
Postoperatively medication was used as in the first case. The recovery period was longer than the first case, The use of elevators with excessive force associated with inadequate movements is mentioned as the most common errors related to iatrogenic displacements [11][12].
Inappropriate use of the dental elevators may provoke the tooth displacement due to a fracture of the buccal thin wall or the complete bone of the tuberosity, which is composed of cancellous bone surrounded by a thin cortical layer. When the tooth is on a very high position and the buccal bone is very thin, the risk of displacement of the impacted tooth in the buccal space is increased [9].
The maxillary third molar, is located very posteriorly on the dental arch; most often, it is located in the posterolateral part of the maxillary tuberosity and presents close relationships with the vasculo-nervous pedicle of the tuberosity, fascia of the buccinator and the infratemporal fossa [3].
The maxillary third molars are limited by the buccal region laterally, the posterior palatal region medially (inside), the infra-temporal side of the maxilla and the infra-temporal fossa posteriorly, the maxillary arch anteriorly, and the maxillary sinus superiorly [10].
The fat bad, filled by adipose tissue, is on the buccal space and extends medially between the ramus and maxillary bone limited medially by the buccinator muscle, superficially by the deep cervical fascia and muscles of facial expression laterally and anteriorly, masseter muscle, mandible and the maxillary alveolar ridge, lateral and medial pterygoid muscles and the parotid gland posteriorly [9]. Buccal fat pad plays a major role in the muscular motions such those needed for the movements of the jaws [12][13][14]. The parotid duct, emerge from the gland and superficially to the masseter muscle opens on the inner surface of the cheek after piercing the buccina-tor muscle usually facing the second molar in the maxilla [11].
The position of the displaced tooth and its relation to other structures should be evaluated with a CT scan or a cone beam computed tomography (CBCT). Radiological images from CT scan or CBCT are required to localize the displaced tooth in two and three dimensions [15].
Radiological exams are suggested immediately before surgical procedure in order to localize the tooth and to ensure that, the displaced tooth would not affect the function of adjacent anatomical spaces [9][10].
The treatment decision for maxillary third molars is based on clinical and radiological information. A CBCT complete study is needed to evaluate the parameters that influence the surgical procedure [15].
Besides the surgical approach, the management of displaced maxillary third molar teeth is influenced by oral surgeon's skill, experience, and adequate surgical tools. A conservative approach to remove tooth from the area ensures less post-operative complications.
Kocaelli et al. [9] reported a displacement of a third molar into the buccal space and concluded that the displacement was related to the luxation of third molar during surgical procedure and we agree with their conclusion. Ohba et al. [10] by using ortho-pan-tomograms (OPG) taken during the path of tooth's migration demonstrated that maxillary third molar should be displaced laterally to the buccinator when displaced into the buccal space.
In our two cases, it has been confirmed, both clinically and radiologically, that teeth were displaced in the buccal space after applying a rotational forces from mesial to distal direction. To avoid surgical complications, careful attention to surgical details, including, a good interpretation of the radiological images, particular management of soft tissues, and a controlled force on the teeth and the hard tissue when applying surgical instruments must be respected. At the end of the treatment, patients showed a high satisfaction of the surgical procedures and no complications were reported. This case report was written after obtaining informed consent from the patient.

Conclusion
Careful attention to surgical details, including, a good interpretation of the radiological images, particular management of soft tissues, and a controlled force on the teeth and the hard tissue should be regarded when applying surgical instruments to avoid such complications.